Dan Ciccarone, MD, MPH

Professor, Family and Community

Medicine

University of California, San Francisco

A More Dangerous ‘Heroin’:

Supply Changes, Adulteration and

Users’ Perceptions

DISCLOSURES

• No financial disclosures

• Some biases:

• A public servant

• Focus on public health

OBJECTIVES

• National data on heroin-related overdose

• Trends

• Demographics

• Regional differences

• Heroin and fentanyl supplies

• Qualitative: users’ perceptions

HEROIN IN TRANSITION (“HIT”) STUDY

• NIH: National Institute of Drug Abuse

• DA037820

• Multi-methodological study: quantitative and qualitative aims

• Supply changes – adulteration – overdose

• New drug forms and user perceptions, adaptation, etc.

PUBLICALLY AVAILABLE DATA:

• Centers for Disease Control and Prevention, National Center for

Health Statistics

• US Drug Enforcement Administration: National Drug Threat

Assessment 2016; National Heroin Threat Assessment, 2015

Leading Causes

of Death• Age-adjusted death

rates for the 10

leading causes of

death in 2015

NCHS Data Brief No. 267 December 2016. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Disease Control and Prevention. National Center for Health Statistics

Mortality in the United States, 2015

0

2

4

6

8

10

12

14

16

Motor Vehicle -Traffic Drug Poisoning

Unintentional

Injury 1999-2012• Age-adjusted death

rates per 100,000 pop.

Produced by: National Center for Injury Prevention and Control, CDC

Data Source: NCHS Vital Statistics System for numbers of deaths. Bureau of Census for population

estimates. Accessed: 11.5.14

An Epidemic of

Crisis Proportion

Numbers of deaths:

• Drug overdose >

• Motor vehicle >

• Gun homicide >

• HIV

Source: New York Times, The Upshot; Josh Katz; April 14, 2017. Data from: Centers for Disease Control

and Prevention, National Center for Health Statistics

US Rx opioid

overdose admissions,

1993-2014:- Apogee reached in 2011

US heroin overdose

admissions,

1993-2014:- Sharp rise, doubling

since 2010

• Rising numbers of

heroin users

• Transitioning from

opioid pills:

• “Intertwined

Epidemics”

• “Every never…”

FUELING HEROIN-RELATED

OVERDOSE

Photo: F. Montero Castrillo

Photo: D. Ciccarone

Google trends: interest

in OxyContin vs heroin

vs _________

• US

• Health category

• Jan. 2006 to Nov.

2014

Data Source: Google Trends (www.google.com/trends)

Search: D Ciccarone, 11.3.14

Analysis: J Unick

NIS: US OVERDOSE RATES (2012-2014)

BY AGE GROUP:

Heroin overdoseOpioid overdose

NIS: OVERDOSE RATES (1993-2014)

BY GEOGRAPHIC REGION:

HOD: Northeast and

Midwest!OPOD: Even –

New England: Large

increases in heroin

OD hospitalizations

for 25-35 yo.

• Rising numbers of

heroin users

• Transitioning from

opioid pills

• Heroin becoming more

dangerous:

• Adulteration

• New forms

FUELING HEROIN-RELATED

OVERDOSE

Photo: D. Ciccarone

FENTANYL LACED HEROIN

• Integrated into heroin supply

• 30-40x stronger than heroin by weight

• Clandestinely-produced fentanyl, not diverted

pharmaceutical fentanyl*

• Analogous: Levamistole as adulterant for

cocaine

*National Heroin Threat Assessment Summary, DEA, 2015

SYNTHETICS

• In addition to fentanyl there are reports of:

Fentanyl analogues:

• Acetyl fentanyl

• Butyryl fentanyl

• Furanyl-fentanyl

• Parafluoro-fentanyl

• Carfentanil

Novel synthetics:

• U47700

• Others…

Photo: D. Ciccarone

FLOW OF FENTANYLS

DEA: National Drug Threat Assessment 2016

CDC: 27 states• Increases in

synthetic opioid

overdose deaths

• Concentrated in

7 states

Gladden RM, Martinez P, Seth P. Fentanyl Law Enforcement Submissions and Increases in Synthetic

Opioid–Involved Overdose Deaths — 27 States, 2013–2014. MMWR

NFLIS: Fentanyl• Testing seized drugs

• Highest rise in rates in

NE and MW

• Recent relative to

earlier rises in

heroin overdose

NATIONAL FORENSIC LABORATORY INFORMATION SYSTEM.

Special Report: Opiates and Related Drugs Reported in NFLIS, 2009–2014. Office

of Diversion Control, DOJ, DEA. 2015

TRENDS IN MORTALITY – TYPE OF

OPIOID

CDC’S LATEST DATA TO 2016

Source: Julia Lurie, Mother Jones, 9.6.2017

http://www.motherjones.com/politics/2017/09/the-latest-jaw-dropping-numbers-from-the-opioid-crisis/

Photo: D. Ciccarone

US heroin seizures are up

~ 140%, 2010-15

CHANGES IN THE HEROIN SUPPLY

Source: National Seizure System. Reported in the 2016 National Heroin Threat

Assessment Summary; DOJ, DEA, 2016

HEROIN SOURCES OVER TIME

Source: Heroin Signature Program. Reported in the 2015 National Drug

Threat Assessment Summary; DOJ, DEA, 2015

• Four sources down to

two

• Colombian dominant

to 2010

• Now Mexican

dominant: 78% in

2014

HEROIN OF UNKNOWN SOURCE

Source: Domestic Monitoring Program. Reported in the 2015 National Drug Threat

Assessment Summary; DOJ, DEA, 2015

MEXICAN TCOs: FLOW OF HEROIN TO

US

MEXICAN-SOURCED HEROIN: CHANGES

• Mexican opium/heroin production has grown while

Colombian production is down 40%

• Explanations for rising HOD in Midwest (in addition to

fentanyl):

• A more purified product coming from Mexico

• “Mexican White:” Colombian mimic

Traditional Colombian-sourced-heroin retail places

Synthetic adulteration > heroin “inconclusive” origin

• The novel entry of Colombian-sourced heroin increased HOD rates; 1993-1999

• New increases in HOD:

• Regional!

• New form of Mexican-sourced heroin

• (+)Fentanyl adulteration

• Wider distribution models

• Young users

SUMMARY: HEROIN IN TRANSITION

Sarah MarsFamily and Community Medicine

University of California, San Francisco

Jeff OndocsinEthnographer and Analyst

HEROIN IN TRANSITION:

THE EXPERIENCES OF

HEROIN INJECTORS

STUDY AIMS

“Hotspot study” where our team of researchers goes to visit

areas in the country where significant changes in the heroin

supply or overdoses have been reported

Baltimore, MD; Lawrence and Lowell, MA; Chicago, IL;

Charleston, West Virginia

Our aim is to understand the experiences and beliefs of the

users themselves and to observe first hand the heroin

currently being used

Photos: D. Ciccarone

1. DEVASTATION: ‘LIKE A ‘COMBAT

STATE’

Now the dope is fentanyl and it’s killing people left and

right. I have over the years, I’ve watched friends [die]—

but on average, it was three a year. Now the last 3 years

it’s been an average of 20 [per year]. I feel like I’m back

in a combat state and I feel like I’m fighting for my life

right now.

Jerry, Lowell, aged 46, using on and off for the

last 20 years

2. CHANGES IN ‘HEROIN’ Users reported and our ethnographers observed wide

variations in the appearance of and effects due to

substances sold as ‘heroin’

Supply not demand driven changes:

– Users surprised and dismayed

– Range of desirability

– No cultural idioms

– Dealers even surprised

We’re supposedly buying dope that doesn’t have any

fentanyl in it, but when I started showing up dirty with

heroin, I started showing up dirty with fentanyl… When

we cut the dope, we don’t use fentanyl. The problem

was that we were buying the dope already dirty with

that and we didn’t know it.

Hector, aged 42, using heroin for 26 years

Lawrence, MA

3. VARIATION AND

UNPREDICTABILITY

Heroin varied by:

- Color: powder and solution

- Intensity of onset or ‘rush’

- Intensity of effect

- Duration of effect (from 45 minutes to 12 hours)

- Types of effect eg sleepy or stimulating

HEROIN SOURCE-FORMS

“Black Tar” Heroin: Mexican

Brown powder Heroin:

Colombian/SWA

White powder Heroin: SEA

NEW HEROIN FORMS

4. DESIRABILITY

The high is wonderful. It’s splendidly wonderful. It’s

magnified heroin feeling by a great number.

Tim, aged 45, using heroin for 25 years, Baltimore

I know a couple of people have done died from that, with

fentanyl, yeah. […] And I have a lot of associates that are

letting me know, “Don’t go to that place because they

selling fentanyl”.

Montana, 39 year old woman using for 21 years,

Baltimore

5. DISCERNMENT

Hierarchy:

- Physiological >

- Taste on the tongue >

- Solution color >

- Powder color

When you add the water to it and pull it back it’s almost

like clear. Heroin’s dark and brown. It’s brown. …but the

fentanyl is like, like water kinda, like a little bit yellowish...

The regular heroin …it can be dark brown or light brown

but it’s never yellow like that.

Kristin, 19 years old, using heroin for 5 years,

Lowell, MA

6. GENERATIONAL CHANGES

• 50 yo African American male, Englewood Chicago about violence in Chicago and the increase in homicides:

• A: A lot of guys are older now, like me. I’m 50 years old. My gang banging days have been over a long time ago. So you got a lot of people with a lot of rank they’re going to jail and they ain’tgetting out no time soon.

• Q: So the youngsters take over?

• A: So the young, so yeah they’re trying to recruit younger guys and these younger guys they’re recruiting they’re putting guns in their hand and they just going buck wild. They’re not following the rules or the laws of the gang that they’re in, they’re trying to rewrite the laws and do what they want to do.

7. TAKING PRECAUTIONS

Like when I get stuff I don’t know what it is I do a little bit

before I do something that I feel. Like I want to kind of

scale out how much I want to do. Because I don’t want to

die. But these people are just doing a gram shot and

just… my friend just died two days ago.

Liz, in her 20s, using heroin for 1.5 years

Lawrence, MA

GO SLOW, STAY IN CONTROL

SUMMARY

Devastation is rampant: individual, social, cultural

Changes in heroin: supply driven

Variation in potency, compounded by fentanyl: ‘Russian

roulette’

Mixed desirability for fentanyl

Some degree of discernment

A new generation needs risk reduction guidance

Some organic harm reduction > pay attention to this!

An Epidemic of

Crisis Proportion

• Crisis with Epic

Opportunity

• Treatment and

Prevention can

work!

Source: New York Times, The Upshot; Josh Katz; April 14, 2017

CRISIS RESPONSE

• Prescription pills ≠ Heroin/fentanyl

• Better surveillance is needed

• Hint: fentanyl as poisoning epidemic

• More evidence-based treatment

• CARA is good but not enough

• Faster responses to overdose

• Stigma remains our biggest enemy

• Harm reduction saves lives, is cost-effective and can bridge people into treatment

• Public safety – Public health collaborations

ACKNOWLEDGEMENTS

Heroin in Transition study:

Jay Unick, Univ. of Maryland

HIT team: Sarah Mars, Jeff Ondocsin, Eliza Wheeler, Mary Howe, Fernando Castillo, Philippe Bourgois, Dan Rosenblum

NIH/NIDA funding: R01DA037820

Chicago:

Dan Bigg, Chicago Recovery Alliance

Baltimore City Health Dept.

Mishka Terplan, Derrick Hunt, Jeffrey Long and NEP staff

Massachusetts:

Gary Langis, Harry Leno, Irving

West Virginia:

Mike Brumage, Tina Ramirez;

Staff and volunteers at Kanawha-Charleston Health Dept.

Jon E. Zibbell

Participants!

Photo credits: Dan Ciccarone, Fernando Castillo